Medicare, TRICARE, and Federal Employee Coverage

If you haven’t read it yet, the coverage overview explains the two gates and the diagnosis backdoor that these plans rely on heavily.

Medicare

The default rule: Medicare Part D has historically excluded drugs used for weight loss. That exclusion still governs standard Part D coverage.

What changed on July 1, 2026: CMS launched the Medicare GLP-1 Bridge, a demonstration program running July 1, 2026 through December 31, 2027. Eligible Part D beneficiaries pay a $50 monthly copay for certain GLP-1 drugs prescribed for weight loss — all formulations of Wegovy (injection and tablets), Wegovy HD, Foundayo, and the Zepbound KwikPen specifically.

How eligibility works. The Bridge is for weight reduction in adults 18 and older who do not have a Part D-eligible diagnosis. If you have obstructive sleep apnea, MASH with moderate-to-advanced fibrosis, type 2 diabetes, or established cardiovascular disease, your request goes to your regular Part D plan instead.

Three things to understand about the $50:

• It does not count toward your Part D deductible
• It does not count toward your annual out-of-pocket cap
• Low-income subsidy assistance does not apply to it

How to start. A pharmacy claim must first be submitted to — and denied by — the Bridge processor before your prescriber submits the prior authorization. Your prescriber submits the request; patients cannot submit it themselves. Beneficiaries can check eligibility at Medicare.gov/glp1bridge or call 1-800-MEDICARE. The Bridge runs outside the normal Part D payment flow, so your Part D plan doesn’t have to opt in for you to use it.

TRICARE

TRICARE matters a great deal in Virginia given Hampton Roads and the Northern Virginia military community. Its criteria (current prior authorization form, dated July 15, 2026) include a step therapy requirement most commercial plans don’t have. For adults seeking Wegovy or the Zepbound Pen Injector for weight management:

• BMI of 27 to 29 with at least one weight-related condition, or BMI of 30 or higher
• Provider attestation of at least 6 months of behavioral modification and dietary restriction that failed, documented in the medical record
• A 3-month trial of generic phentermine, benzphetamine, diethylpropion, or phendimetrazine that failed to produce 5% weight loss — unless you have a contraindication, had an adverse reaction, or lost 5% but still need further reduction
• Not pregnant, not using another GLP-1, and no personal or family history of medullary thyroid cancer or MEN type 2

The prescriber must be an MTF or TRICARE network provider who has billed TRICARE for assessing you and developing a treatment plan. This is a hard stop — the request is denied without it.

Ages 12 to 17: only Wegovy injection is available, requiring BMI at or above the 95th percentile. Approval runs 12 months, with annual renewal requiring at least 5% weight loss from baseline (4% for ages 12 to 17). For Zepbound and sleep apnea: adults with a documented apnea-hypopnea index of 15 or more events per hour and BMI of 30 or higher; Wegovy is not covered for this indication. Quantity limits are a 30-day supply at retail, up to 60 days by mail order.

Federal employees (FEHB)

Relevant across Northern Virginia. For plan year 2026, OPM required all FEHB plans to cover at least one GLP-1 prescribed for weight loss plus at least two additional oral anti-obesity medications — so some coverage exists in every FEHB plan, though which drug is preferred varies. Prior authorization applies, and most carriers use the BMI 30, or 27-with-comorbidity standard.

Looking ahead: for plan year 2027, OPM has told carriers it will require enrollees to participate in intensive behavioral therapy both before and during coverage of anti-obesity medications. Expect FEHB requirements to tighten.

Frequently asked questions

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